In the JournalsPerspective

Transgender, gender nonconforming teens have diminished perceptions of health

Nic Rider

Teenagers who identify as transgender and gender nonconforming are more likely to report poorer physical and mental health than those who identify as cisgender, with less use of preventive health care measures, according to findings published in Pediatrics.

Additionally, perceptions of health were varied based on perceived gender expression of these students, with the largest representation of students reporting a gender perception of equally masculine and feminine.

“Some of our previous research indicates that, when compared to cisgender youth, [transgender and gender nonconforming (TGNC)] adolescents report experiencing higher rates of bullying and subsequently higher rates of emotional distress and substance use following from these incidents,” Nic Rider, PhD, from the Program in Human Sexuality in the department of family medicine and community health at the University of Minnesota, Minneapolis, told Infectious Diseases in Children.

These health outcomes may also be a result of negative experiences such as discrimination and other interactions that do not affirm their gender identities and expressions, which other studies indicate does happen in health care settings,” Rider continued.

To assess health care use among adolescents who are TGNC, as well as their mental and physical health status compared with cisgender adolescents, who identify with the sex they were born with, the researchers conducted an analysis that examined data collected in the 2016 Minnesota Student Survey.

Participants included teenagers between grades nine and 11 who reported gender expression, four different measures of health status and their use of health care in three areas. Rider and colleagues conducted this analysis by using chi-squares and multiple interpretations of covariance tests, which controlled for covariates for each demographic.

Of the 80,929 students included in the survey, 2.7% identified as TGNC and 97.3% identified as cisgender. The researchers observed that TGNC adolescents were more likely to have been assigned female at birth, of color or given free or reduced-price lunches compared with cisgender students. Rider and colleagues did not observe a difference in identity based on physical location (metropolitan vs. nonmetropolitan).

When assessing health status, 62.1% of TGNC youth reported a health status other than ‘very good’ or ‘excellent.’ The researchers noted that this rate was nearly double that of cisgender adolescents (33.1%; P < .001). Additionally, 59.3% of TGNC adolescents reported long-term mental health concerns, compared with 17.4% of cisgender teenagers (P < .001), and 51.5% of TGNC reported being absent from school for at least 1 day within the past month (cisgender = 42.6%). Despite these health concerns, TGNC youth used preventive medical and dental health care and more frequently visited the school nurse.

Regarding perceived gender expression, adolescents who were equally feminine and masculine encompassed the largest group of TGNC teenagers (assigned male sex = 29.3%; assigned female sex = 41.2%). The effect of perceived gender on health status was significant for students who identified as TGNC and were assigned male sex at birth (P < .001). This difference was statistically significant for at least two groups regarding general health and long-term mental health concerns.

For those assigned male sex at birth, poor general health was most frequently reported by those who perceived themselves as equally masculine or feminine (49.2%) or somewhat masculine (57.5%). These rates were high compared with those who identified as very masculine (32.1%). Those who identified as anything other than very masculine were more likely to have long-term mental health concerns (range = 40.7%-45.7%).

Those who were assigned female sex at birth were significantly more likely to have general health concerns if they perceived themselves as somewhat feminine (69.5%), equally feminine and masculine (70.4%) or somewhat masculine (71.7%). More than half of teenagers assigned female sex at birth who perceived themselves as very feminine reported poor health (54.0%). Similar to those assigned male sex at birth, those assigned female sex with any gender expression other than very feminine were more likely to have long-term mental health concerns (range = 68.1%-76.7%).

“When health care providers do have the opportunity to work with TGNC adolescents, it is important to ask them about these health risks as well as barriers they experience in terms of accessing, utilizing and receiving competent and quality care,” Rider said. “It is especially important for health care providers to also identify and refer to appropriate follow-up care when necessary. These are some of the ways health care providers can bolster wellness within this community.” – by Katherine Bortz

Disclosure: The authors report no relevant financial disclosures.

Nic Rider

Teenagers who identify as transgender and gender nonconforming are more likely to report poorer physical and mental health than those who identify as cisgender, with less use of preventive health care measures, according to findings published in Pediatrics.

Additionally, perceptions of health were varied based on perceived gender expression of these students, with the largest representation of students reporting a gender perception of equally masculine and feminine.

“Some of our previous research indicates that, when compared to cisgender youth, [transgender and gender nonconforming (TGNC)] adolescents report experiencing higher rates of bullying and subsequently higher rates of emotional distress and substance use following from these incidents,” Nic Rider, PhD, from the Program in Human Sexuality in the department of family medicine and community health at the University of Minnesota, Minneapolis, told Infectious Diseases in Children.

These health outcomes may also be a result of negative experiences such as discrimination and other interactions that do not affirm their gender identities and expressions, which other studies indicate does happen in health care settings,” Rider continued.

To assess health care use among adolescents who are TGNC, as well as their mental and physical health status compared with cisgender adolescents, who identify with the sex they were born with, the researchers conducted an analysis that examined data collected in the 2016 Minnesota Student Survey.

Participants included teenagers between grades nine and 11 who reported gender expression, four different measures of health status and their use of health care in three areas. Rider and colleagues conducted this analysis by using chi-squares and multiple interpretations of covariance tests, which controlled for covariates for each demographic.

Of the 80,929 students included in the survey, 2.7% identified as TGNC and 97.3% identified as cisgender. The researchers observed that TGNC adolescents were more likely to have been assigned female at birth, of color or given free or reduced-price lunches compared with cisgender students. Rider and colleagues did not observe a difference in identity based on physical location (metropolitan vs. nonmetropolitan).

When assessing health status, 62.1% of TGNC youth reported a health status other than ‘very good’ or ‘excellent.’ The researchers noted that this rate was nearly double that of cisgender adolescents (33.1%; P < .001). Additionally, 59.3% of TGNC adolescents reported long-term mental health concerns, compared with 17.4% of cisgender teenagers (P < .001), and 51.5% of TGNC reported being absent from school for at least 1 day within the past month (cisgender = 42.6%). Despite these health concerns, TGNC youth used preventive medical and dental health care and more frequently visited the school nurse.

Regarding perceived gender expression, adolescents who were equally feminine and masculine encompassed the largest group of TGNC teenagers (assigned male sex = 29.3%; assigned female sex = 41.2%). The effect of perceived gender on health status was significant for students who identified as TGNC and were assigned male sex at birth (P < .001). This difference was statistically significant for at least two groups regarding general health and long-term mental health concerns.

For those assigned male sex at birth, poor general health was most frequently reported by those who perceived themselves as equally masculine or feminine (49.2%) or somewhat masculine (57.5%). These rates were high compared with those who identified as very masculine (32.1%). Those who identified as anything other than very masculine were more likely to have long-term mental health concerns (range = 40.7%-45.7%).

Those who were assigned female sex at birth were significantly more likely to have general health concerns if they perceived themselves as somewhat feminine (69.5%), equally feminine and masculine (70.4%) or somewhat masculine (71.7%). More than half of teenagers assigned female sex at birth who perceived themselves as very feminine reported poor health (54.0%). Similar to those assigned male sex at birth, those assigned female sex with any gender expression other than very feminine were more likely to have long-term mental health concerns (range = 68.1%-76.7%).

“When health care providers do have the opportunity to work with TGNC adolescents, it is important to ask them about these health risks as well as barriers they experience in terms of accessing, utilizing and receiving competent and quality care,” Rider said. “It is especially important for health care providers to also identify and refer to appropriate follow-up care when necessary. These are some of the ways health care providers can bolster wellness within this community.” – by Katherine Bortz

Disclosure: The authors report no relevant financial disclosures.

    Perspective

    In this study published in Pediatrics, Rider, et al have produced the most systematic analysis to date of the increased medical and mental health morbidity suffered among transgender/gender nonconforming youth. As the authors report, previous studies are either of adult populations or are confounded by convenience samples. The Rider study is notable because it mined a defined database. Even other large studies of transgender individuals suffer from the absence of good controls, often utilizing large scale survey methods where there is no good understanding of how participants might differ from the general population. The database approach in the Rider study allowed the authors to use the remainder of the database as a reliable control.  The Rider study is further of interest because it separated transgender and gender nonconforming adolescents into subcategories in an attempt to ascertain if there might be differences between those who are more binary in their identities relative to those who are more non-binary.

    Transgender individuals suffer significantly increased medical and mental health morbidity compared with non-transgender individuals (Safer, et al, Current Opinion in Endocrinology, Diabetes and Obesity).  The increased morbidity can be attributed to myriad barriers to quality transgender health care, along with the stigma assigned to transgender individuals in most societies.  Leinung, et al observed in a study in Endocrine Practice that both lowers the ages of presentation among his patients for transgender hormone therapy in his endocrinology practice over time along with decreased rates of mental health morbidity. (Although the trend observed by Leinung seems likely to be occurring more broadly, the data presented by Rider, et al demonstrate how much work remains to be done.

    The Rider study provided rigorous documentation for disparities long suspected.  However, underlying explanations for the findings and interventions to address them remain large knowledge gaps that will require much future study.  We anticipate that more robust approaches to teaching transgender medical care will have positive outcomes (Park, et al, Transgender Health) but the details of what strategies to employ remain untested.  Further research is needed to demonstrate successful education strategies and models for delivering care more successfully.  Then, longitudinal analyses of cohorts and databases like those used by Rider, et al will provide the opportunity to measure actual benefit to patients over time.

    • Joshua D. Safer, MD, FACP
    • Executive director, Center for Transgender Medicine and Surgery Mount Sinai Health System and Icahn School of Medicine at Mount Sinai

    Disclosures: Safer reports no relevant financial disclosures.